« Back to part 2 (Migraines)

CLUSTER HEADACHES

Cluster headaches is a distinct, although rare, clinical entity that occurs in 0.5% of the population.²⁰ Attacks of headache occur several times a day in "clusters" for several days or weeks at a time. The headaches are shorter than migraine, last from 15 to 30 minutes and up to 2 to 3 hours. The pain is usually severe, knife-like, unilateral and usually centered around the orbits or supraorbital area. Autonomic features such as conjunctival injection, lacrimation, nasal congestion, rhinorrhea, miosis, ptosis and eyelid edema are all part of the syndrome. Patients are then headache-free between clusters.

Unlike migraine, cluster headache is predominantly a young male disorder beginning between ages 27 through 31, with a male to female ratio of 4 to 1.

Treatment of Cluster Headaches

1. Oxygen is the standard recommended treatment with 100% oxygen being administered at 7 to 10 liters/minute for approximately 15 minutes. Approximately 70% of patients will get some relief from their pain.
2. Subcutaneous Sumatriptan is the most effective medication for acute symptoms. The medication may have to be repeated with a second dose.
3. Prednisone given in large doses during an attack will help suppress headaches.

MRI OF THE BRAIN IN MIGRAINE

MRI's of the brain are being ordered with increasing frequency, and often the primary care providers are concerned about reports which describe white matter abnormalities.¹³ White matter abnormalities are very common in patients with migraine, the prevalence ranging from 12% to 46%. The clinical significance of these abnormalities is unclear. The differential diagnosis of white matter lesions in the brain MRI is shown in TABLE 14.

MIGRAINE MISDIAGNOSIS

Many that suffer from headaches and other disorders are actually migraine sufferers and candidates for migraine specific therapy.²

Millions of patients remain undiagnosed, incorrectly diagnosed, or ineffectively treated. It takes an average of 3.5 years for a patient to find effective treatment. Patients try an average of nearly five different options before obtaining effective treatment for migraine.^21,22 Migraine is often overlooked. It is overlooked in many patients who are diagnosed with sinus headaches. The typical history of a patient with a sinus headache is:

1. A dull ache located near the nose.
2. Pressure over a sinus cavity.
3. Thick, colored nasal discharge.
4. Fever.
5. Over-the-counter medications sometimes relieve the pain.

While acute purulent sinusitis can cause a headache, the so-called sinus headache without the above nasal symptoms is likely a migraine headache. A triptan should be tried, unless there are contraindications to triptan use.

Tension-type headaches are also a frequent misdiagnosis. If the patient presents with throbbing neck pain associated with such symptoms as nausea and/or vomiting and disability, such as bed rest, or interferes with daily activities, one should consider the diagnosis of migraine. Again, the patient may respond to a triptan.

TENSION-TYPE HEADACHE - DIAGNOSIS AND TREATMENT

Introduction

Tension-type headache is the most common headache disorder.²³ The ratio of women to men with tension-type headache is approximately 5 to 4. In the past "tension headache" was a poorly defined term, usually associated with psychopathology and attributed to excess muscle contraction, usually in the muscles of the neck or scalp.

The International Headache Society (IHS) classification of 1988, redefined this entity to include episodic tension-type headache (ETTH) and chronic tension-type headache (CTTH).

Episodic tension-type headache (ETTH) is defined as recurrent episodes of a headache meeting the following criteria.

1. Headache lasting from 30 minutes to seven days
2. At least two of the following pain characteristics:
   1. Pressing or tightening, non-pulsating quality
   2. Mild or moderate intensity
   3. Bilateral location
   4. Not aggravated by physical activity or walking stairs
3. No nausea or vomiting. Photophobia and phonophobia are usually absent, but one may be present.
4. The number of days with such headaches is less than 15 per month.

Chronic tension-type headaches (CTTH) have all the criteria and pain characteristics mentioned above for episodic tension-type headaches. In addition, the headaches usually occur for more than 15 days per month. Chronic tension-type headache is often associated with severe pain and often associated with medication over-usage.

Treatment

One of the most important elements in treating tension-type headaches, and headache patients in general, is to take their complaints seriously, and examine them thoroughly.

Treatment of Tension-Type Headaches

1. NONPHARMACOLOGIC - BEHAVIORAL.
2. PHARMCOLOGIC.

NONPHARMACOLOGIC - BEHAVIORAL

1. Reassurance and counseling on stress management.
2. Relaxation therapy.
3. Biofeedback.
4. Physical therapy including heat and cold packs, ultrasound, electrical stimulation.
5. Trigger point injections or occipital nerve block.

PHARMACOLOGIC

1. Milder analgesics such as aspirin and acetaminophen, and nonsteroidal anti-inflammatories such as naproxen or ibuprofen.
2. Stronger analgesics such as Tylenol® with Codeine or Fiorinal® with Codeine.
3. The newer anti-inflammatory agents such as Celebrex®.
4. Stress reduction medications such as Tranxene®, Xanax®, and BuSpar®. When using these medications mentioned in #1 and #2 above, one has to be sure the patient is not converted from an episodic tension-type headache to a chronic tension-type headache or rebound headache.²³

CHRONIC DAILY HEADACHE (CDH)

There is no consensus on the classification of daily and near daily headaches, often known as chronic daily headaches (CDH)²⁴.

Chronic daily headache is an umbrella term that includes chronic migraine (CM), transformed migraine (TM), chronic tension- type headache (CTTH), or any headache that occurs on a daily or near daily basis. Most use CDH to refer to people with more than 15 headache days per month, not related to a structural or systemic illness. Others use daily headaches associated with medication overuse as chronic daily headaches or rebound headaches.

CHRONIC MIGRAINE OR TRANSFORMED MIGRAINE: Patients often have a history of episodic migraine. Most patients are women, 90% of whom have a history of migraine that begins in their teens or 20's.²⁴ Often the patients complain of a process of transformation characterized by headaches that have grown more frequent over months to years with the associated symptoms of photophobia, phonophobia, and nausea becoming less frequent over the years.

These patients often develop a pattern of daily or near daily headaches that resemble chronic tension-type headaches. That is, the pain is of mild to moderate intensity and not associated with photophobia, phonophobia or gastrointestinal features. Patients with chronic migraine or transformed migraine frequently have a family history of headaches, depression, anxiety, panic disorders, bipolar disorders, fibromyalgia, and/or alcohol abuse. Eighty percent of people with transformed migraine have depression. Medication overuse occurs in more than 80% of the patients with chronic daily headaches.

Although migraine transformation may develop as a result of medication overuse, transformation may occur without overuse.

CHRONIC TENSION-TYPE HEADACHES (CTTH): Daily headaches may also develop in patients with a history of episodic tension-type headaches (ETTH). These headaches are more often diffuse or bilateral, frequently involving the posterior aspect of the head and neck.²⁴

DRUG OVERUSE AND REBOUND HEADACHES: Patients with frequent headaches often overuse analgesics, opiates, and ergotamines. In headache prone patients, medication overuse may produce drug induced "rebound headaches" that is accompanied by dependence on medication. Most patients with drug induced headaches have a history of episodic migraine that has converted to transformed migraine as a result of medication overusage.

Treatment of Chronic Daily Headaches

Patient management of the patient should take into account the treatment of any comorbid psychiatric disorders that the patient may exhibit.

Non-pharmacologic treatments may be necessary. Behavioral psychotherapy with patient education and lifestyle changes have to be instigated. Included in the lifestyle changes should be exercise and sleep pattern changes.

In addition, preventative or prophylactic treatments of the headache may be needed, including antidepressants, beta blockers, anticonvulsants, calcium channel blockers, either alone or in combination.

In cases of medication overuse or rebound headaches, the first treatment should be to discontinue the offending medication causing the chronic daily headache, or rebound headache, with adequate preparation for adverse events related to the withdrawal. Sometimes the medication being withdrawn has to be withdrawn gradually over a period of weeks. While the medication is being tapered, anti-inflammatory agents such as steroids or NSAIDS may be needed.

Chronic daily headache is a difficult disorder to treat and may necessitate referral to a neurologist or headache specialist. Many of the patients will change doctors frequently to obtain their drug of choice or alternative analgesics, rather than face their primary problem which may be psychiatric. Hospitalization is sometimes needed in cases of refractory chronic migraine or chronic daily headache.

CONCLUSION

Headache is one of the most common reasons patients seek help from primary health care providers. It is affects nearly one in every four households in the United States. A brief neurological examination is important in determining whether a headache is either primary or secondary. Migraine distinguishes itself among the primary headaches because of the tremendous misdiagnosis and disability associated with it. Frequently migraine is misdiagnosed as either sinus headaches and/or tension-type headaches. Treatment with triptans can relieve the head pain, as well as associated symptoms of photophobia, nausea, and/or vomiting. Chronic daily headache is often associated with medication overuse, particularly combination analgesic and ergotamines. Primary health care providers play a pivotal role in relieving the pain and impact headaches have on the lives of their patients.

1. Multiple sclerosis

2. Cerebrovascular disease and ischemia

3. Hypertension, diabetes mellitus, hyperlipidemia, and coagulopathies (all stroke risk factors)

4. Vasculitis (including systemic lupus erythematosus, Sjogren's syndrome)

5. Antiphospholipid antibody syndrome

6. Infections such as Lyme's disease, HIV

7. Migraine

8. Unknown